Comparative Analysis of Intramedullary Nail versus Plate Fixation for Fibula Fracture in Supination External Rotation Type IV Ankle Injury

Background

Lateral malleolus fractures represent a frequently encountered lower leg injury resulting from various etiologies, such as traumatic events, sports-related incidents, or accidental occurrences. Among ankle fractures, the supination external rotation (SER) injury pattern is highly prevalent, accounting for approximately 85% of all cases [1]. The SER injury occurs when a supinated foot experiences axial loading. The subtalar joint, characterized by its complex axis of movement [2], functions as an angulated hinge, leading to external rotation of the talus in response to calcaneus inversion [3]. This injury pattern is analogous to Weber B fractures. SER type IV ankle fractures are considered particularly unstable and necessitate surgical intervention, which typically involves addressing both lateral malleolus fractures and concurrent medial malleolus fractures or deltoid ligament injuries. The influence of minor clinical characteristics, such as chronic diseases and skeletal disorders, like osteoporosis, on fracture healing is a crucial aspect of orthopedic research. These factors can significantly affect the treatment outcomes and recovery process, warranting thorough consideration in the assessment of fracture management strategies. Understanding their effects on fracture healing is essential for optimizing patient care and treatment decisions in orthopedic practice.

The primary objectives in managing ankle joint fractures are to restore proper alignment of the lateral malleolus and preserve the integrity of the weight-bearing joint surface, thereby ensuring stability and mobility of the ankle joint [4]. In the context of treating fibula fractures associated with SER type IV injuries, 2 commonly used techniques are intramedullary nail fixation and plate fixation. Each method has distinct advantages and considerations. Traditionally, lateral or posterolateral plate fixation was widely favored for the management of spiral fibular fractures associated with SER type IV injuries. However, owing to their inherent biomechanical advantages, such as excellent stability, facilitation of anatomical reduction, and less soft tissue disruption, intramedullary nails have gained increasing popularity among certain surgeons.

In the present study, we aimed to compare the 2 fixation approaches to help enable patients and healthcare professionals to make well-informed decisions regarding the most suitable method for addressing fibula fractures in the context of SER type IV injuries.

Material and Methods

A prospective and randomized study was conducted to assess the efficacy of locking intramedullary nail fixation vs locking plate fixation for fibula fractures in SER injuries. In this study, patients were randomly assigned to either the intramedullary nail fixation group or the locking plate fixation group using a randomization sequence executed by an independent statistician uninvolved in subsequent study phases. Patients and surgeons were blinded to group assignments, receiving identical-looking interventions to prevent bias. Data collectors responsible for outcome assessments were also blinded, ensuring unbiased data collection and analysis. Blinding procedures were consistently maintained, and any unblinding events were promptly documented and addressed, upholding the study’s scientific integrity. Randomization was achieved using a random table of numbers to allocate patients to either the nail or plate group. A total of 81 patients with SER injuries were included in the study, all of whom were treated at our department between January 2021 and December 2021.

Inclusion criteria for participation in the study included closed fractures, SER IV injuries with medial malleolus fractures, Haraguchi type III posterior maleolus fractures, and an age range from 18 years to 65 years. Exclusion criteria were bilateral injuries, open fractures, associated injuries in other anatomical sites, osteoporosis, pathological fractures, and basic chronic diseases and some skeletal disorders.

Under general anesthesia, all patients underwent reduction and fixation of lateral and posterior malleolus fractures while positioned in the lateral recumbent position. Subsequently, patients were placed in the supine position for open reduction and internal fixation of medial malleolus fractures. Following surgery, a progressive weight-bearing protocol was initiated, and rehabilitation commenced 6 weeks after surgery. No postoperative plaster casts were applied.

To evaluate the outcomes of the 2 groups (nail group and plate group), various parameters were recorded, including complications, operation times, bone healing times, American Orthopaedic Foot & Ankle Society (AOFAS) scores, visual analog scale (VAS) scores for pain assessment, ankle range of motion, and radiographic parameters of medial clear space, tibiomedial malleolar angle, fibular length, talocrural angle, and tibiofibular clear space. Statistical analysis was performed using SPSS software (version 15.0.1, SPSS Inc., Chicago, IL, USA). The Wilcoxon rank-sum test was used for non-parametric data analysis, while the chi-square test was used for comparing rates. A significance level of P<0.05 was considered statistically significant.

Results

In this study involving 81 patients with SER injuries, in which each patient represented a single injury case, the treatment outcomes between the 2 groups were rigorously assessed. Among these patients, 42 underwent intramedullary nail treatment (nail group, Figure 1), while 39 received plate fixation (plate group, Figure 2) (Table 1). All patients received at least 1 year of follow-up. The fracture healing time in the nail group was an average of 9.34±1.97 weeks, and 9.12±1.55 weeks in the plate group; no significant difference was found (P>0.05). A critical observation in our findings was the incidence of postoperative complications. The nail group exhibited a significantly lower complication rate, with only 9.52% of cases experiencing issues, in contrast to the plate group, which showed a considerably higher complication rate, at 30.77% (P=0.0164), as shown in Table 2. However, it is noteworthy that no significant differences were identified between the nail group and plate group in terms of bone healing time (P=0.7725), AOFAS scores (P=0.6363), VAS scores for pain (P=0.6264), and functional evaluations, as shown in Tables 3 and 4. These comprehensive results highlight the clinical benefits of intramedullary nail treatment in reducing postoperative complications, which is a significant consideration in the management of SER injuries, while also indicating that both treatment modalities yielded similar outcomes in terms of bone healing and functional recovery.

Discussion

The selection of internal fixation methods for fibula fractures remains a topic of debate within the medical community. Two commonly employed techniques are intramedullary nail fixation and plate fixation. While some comparative studies have been conducted to compare these methods [5–8], there is a relative lack of studies specifically focusing on fibula fractures in the context of SER type IV injuries.

The plate fixation technique offers excellent stability and enables precise control over alignment during surgery [9,10]. It is particularly favored for complex or comminuted fractures involving multiple bone fragments [5,11]. Plate fixation allows for superior control over the alignment of bone fragments, facilitating precise anatomical reduction and stable fixation. This feature is especially beneficial for complex fractures that necessitate structural alignment [12]. Furthermore, the presence of a metal plate provides immediate stability to the fractured bone, enabling early weight-bearing and promoting accelerated healing. It facilitates early mobilization and reduces the risk of malalignment [12]. Moreover, plate fixation permits customized contouring of the plate to match the specific shape of the fibula, ensuring an optimal fit and enhanced stability [13].

However, plate fixation also has certain considerations. Of note, the procedure of plate fixation involves a larger incision, which can result in greater soft tissue disruption. This can lead to increased postoperative pain, swelling, and a longer recovery period [14]. More importantly, the presence of metal plates and screws can occasionally cause irritation or discomfort. In some cases, the hardware may need to be removed following bone healing [15].

Therefore, as another common technique for fibula fractures, intramedullary nail fixation is widely used in SER injury. Compared with plate fixation, intramedullary nail fixation is a minimally invasive procedure. It requires a smaller incision, resulting in reduced soft tissue damage, decreased pain, and faster recovery [16]. Notably, the intramedullary nail bears a significant portion of the body’s weight, providing load-sharing capabilities. This promotes stability, enhances healing, and allows for early weight-bearing [8]. In addition, since the nail is inserted within the medullary canal, it causes less disruption to the surrounding soft tissues, including blood vessels and muscles [17].

Similar to plate fixation, there are also considerations for intramedullary nail fixation. Compared with plate fixation, intramedullary nail fixation offers less control over precise alignment. It may not be suitable for fractures requiring intricate anatomical reduction [18]. Furthermore, improper insertion or inadequate rotational control during intramedullary nail fixation can result in malrotation of bone fragments, potentially leading to functional issues or cosmetic deformities [19]. In the present study, we found that the incidence of postoperative complications was lower in the intramedullary nail group than in the plate fixation group. However, there were no significant differences between the 2 groups regarding operation time, bone healing time, AOFAS score, VAS score, and functional evaluations. Based on these results, it is preferable to use the intramedullary nail technique for managing fibula fractures in the context of SER type IV injuries.

Nevertheless, this study had limitations. First, the number of included cases was limited, and, second, it was not a long-term study. Further, the success of the intramedullary nail technique was highly dependent on the skill and experience of the surgeon, as there is a learning curve associated with this procedure. An experienced surgeon can have shorter operation times and use additional surgical techniques, which could potentially impact the complication rate and functional outcomes.

Conclusions

Plate and intramedullary nail fixation are effective for fibula fractures, and the choice of technique depends on factors such as fracture type and patient characteristics. Plates excel in precise alignment control, making them suitable for complex fractures. In contrast, intramedullary nails offer advantages including fewer complications, minimally invasive surgery, load sharing, and soft tissue preservation, as supported by our study findings that indicated lower complication rates with this method. In cases of SER type IV injuries, intramedullary nails may be a preferred option, but the decision should be individualized. Preoperative evaluation plays a crucial role in guiding the choice to optimize healing and patient recovery.